There are many causes of low back pain, and it affects a lot of people in daily life. In strength and conditioning, the issue often shows up on the weight room floor. Lifters who routinely use movement patterns that put the spine in end-range loaded flexion or extension risk their low back health and performance. This isn’t to say that all flexion or extension is bad; the spine is built to move, provided there isn’t excessive compensation, mobility limits, and appropriate restraints from both passive (ligaments, labrums, tendons) and active (muscles) structures.
The problem arises when the spine is loaded in ranges of motion that can’t be controlled, often in pursuit of social media validation. There are many examples of lifters—mostly at elite levels—who use techniques that increase the risk of spinal issues worldwide. A respected biomechanical view on this is that a rounded-back deadlift can have benefits, but back pain can strike suddenly or from everyday tasks like bending to pick up a pencil or tying shoes.
Two common scenarios explain most low back pain:
1) A one-time blunt trauma, such as the spine buckling under load, a car accident, or a fall.
2) A repetitive aberrant movement pattern, such as tissue creep from sustained spinal flexion at work.
Dr. Stuart McGill’s work on spinal biomechanics has been a key resource for many, including me, to guide assessment and understand root causes. He introduced the idea of “spinal hygiene,” emphasizing the value of evaluating a client’s movement to identify what worsens their pain.
From McGill’s perspective, the goal of assessment is to provoke pain in a controlled way to identify which postures, motions, and loads trigger or amplify pain and which movements can be pain-free alternatives.
People who experience more pain with flexion (slouching, sitting, bending forward) are often viewed as flexion intolerant, while those with more pain in extension (standing for long periods, bending backward, excessive arching in training) are seen as extension intolerant. Ironically, relief often comes from postures that may perpetuate the dysfunction.
What’s the fix? In practice, many approaches in physical therapy can help. There are numerous therapies that have helped people recover from low back pain, so there isn’t a single universal answer. Treatments can include manual therapies, mobility work, breathing, and techniques that address the root causes. An effective approach often blends methods to fit the individual.
Passive approaches (like certain modalities that focus on short-term relief) can help symptoms but may not address underlying causes. Active approaches tend to focus on the root problems—poor movement quality, posture, muscle weakness, and mobility restrictions—and involve educating the client to prevent future setbacks. The aim is to establish a neutral spinal position and pain-free movement.
In my view, an active approach is typically more reliable. The idea isn’t to chase a miracle cure, but to restore safe, sustainable movement.
What about the “forgotten” cause? It’s not forgotten, but often overlooked. Beyond flexion or extension intolerance, many people have pain related to spinal instability, especially when rotation enters the picture. The body moves in multiple planes, and instability can show up when you venture beyond sagittal plane movements (like into frontal or transverse plane motions). The stabilizing muscles around the spine may be under-active and need extra training. Some people who can squat heavy and tolerate compression still experience low back pain with rotational movements. The fix is to help them find and maintain a neutral spine and improve motion in the hips and thoracic spine.
What exercises fit into a pain-free movement approach when instability is present? A few key ones:
– Planks: Core endurance matters for spinal stability, but they must be done in proper positions. Avoid poor form or excessive fatigue.
– Low-load, controlled variations: the RKC plank helps build full-body tension. Start with a bit of flexion and work toward a neutral spine. Variations like three-point planks (reducing base of support) or prone plank arm marches can raise the challenge gradually. Wall-supported planks or transitions can teach the torso to stay still while the rest of the body moves safely.
– Dead bugs: When performed correctly, they’re excellent for building core and spine stability. Focus on a full exhale and controlled, hip-driven motion. A wall-press variation with higher repetitions can be effective for endurance.
Other useful tools for stability and rotation control include:
– Offset-loaded lifts (unilateral dumbbell work or offset barbell presses) to force the core to resist rotation.
– Shovel deadlifts.
– Farmer carries, particularly with one arm, to train anti-rotation and spinal stability.
– One-legged anti-rotation movements (like the one-legged anti-rotation scoop toss), which can be tougher than they look.
– Anti-rotation presses, which increase core strength and stability. Adjust difficulty with stance width.
This isn’t an exhaustive list, but it provides a solid starting point for many dealing with low back pain. If you have ideas or approaches of your own, feel free to share them. Movement is inherently multi-planar, and many of these movements can help with both flexion- and extension-based issues. If you’re training, stay focused on maintaining a neutral spine and building stable, pain-free movement patterns.
